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PO Box 474
4 Calle Pedro Marquez
Culebra, PR 00775
787-742-0803

 

RELEASE OF LIABILITY, WAIVER OF CLAIMS, EXPRESS ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICTIONS OF SIGNING

EXPRESS ASSUMPTION OF RISK ASSOCIATED WITH DIVING AND RELATED ACTIVITIES

Any photos taken by Culebra Divers are property of Culebra Divers. I understand and agree photos taken may include myself and could be used on any and all forms of social media including Culebra Divers website. 

I Agree

I do hereby affirm and acknowledge that I have been fully informed of the inherent hazards and risks associated with Snorkeling, Skin and/or Scuba diving. I fully understand that these risks can lead to severe injury and even loss of life. I understand that diving operations may be conducted at a site that is remote from a recompression chamber and competent medical assistance. Nevertheless, I choose to proceed even in the absence of a recompression chamber and competent medical assistance. Additionally, I understand that there are also risks associated with dive travel, including, but not limited to the possible injury or loss of life as a result of a dive boat accident, as well as travel to and from dive sites. Despite the potential hazards and dangers associated with the activity of diving, I wish to proceed and I freely accept and expressly assume all risk, dangers and hazards that may arise from diving activities which could result in personal injury, loss of life and property damage to me.  

I Agree

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT:

In consideration of being allowed to participate in Snorkeling, Skin and/or Scuba Diving activities as well as the use of any of the facilities and the use of the equipment of the below listed releasees, I hereby agree as follows:

1. TO WAIVE AND RELEASE ANY AND ALL CLAIMS based upon negligence, active or passive with the exception of intentional, wanton or willful misconduct that I may have in the future against any of the following named persons or entities (hereafter referred to as Releasees): 

(Instructor/s) All Staff & Instructors
(Facility/ies) Culebra Divers

2. To release the releasees, their officers, directors, employees, representatives, agents and volunteers, from liability and responsibility, whatsoever,
for any claims or causes of action that I, my estate, heirs executors or assigns may have for personal injury, property damage or wrongful death arising from Snorkeling, Skin and / or Scuba diving activities whether caused by active or passive negligence of the releasees or otherwise with the exception of gross negligence. By executing this document, I agree to hold the releasees harmless for any injury or loss of life which may occur to me during Snorkeling, Skin and/or Scuba diving activities and/or instruction.

3. By entering into this agreement, I am not relying on any oral or written representation or statements made by the releasees, other than what is set forth in this agreement. I further agree that this Agreement shall be governed by and interpreted in accordance with the laws of the State of California, United States of America.

4. If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
I hereby declare that I am of legal age and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT.

I Agree

STANDARD SAFE DIVING PRACTICES STATEMENT OF UNDERSTANDING

Please read carefully before initialing.

This is a statement in which you are informed of the established safe diving practices for skin and scuba diving. These practices have been compiled for your review and acknowledgement and are intended to increase your comfort and safety in diving. Your signature on this statement is required as proof that you are aware of these safe diving practices. Read and discuss the statement prior to signing it. If you are a minor, this form must also be signed by a parent or guardian.

I understand that as a diver I should:

1. Maintain good mental and physical fitness for diving. Avoid being under the influence of alcohol or dangerous drugs when diving. Keep proficient in diving skills, striving to increase them through continuing education and reviewing them in controlled conditions after a period of diving inactivity, and refer to my course materials to stay current and refresh myself on important information.

2. Be familiar with my dive sites. If not, obtain a formal diving orientation from a knowledgeable, local source. If diving conditions are worse than those in which I am experienced, postpone diving or select an alternate site with better conditions. Engage only in diving activities consistent with my training and experience. Do not engage in cave or technical diving unless specifically trained to do so.

3. Use complete, well-maintained, reliable equipment with which I am familiar; and inspect it for correct fit and function prior to each dive. Have a buoyancy control device, low-pressure buoyancy control inflation system, submersible pres- sure gauge and alternate air source and dive planning/monitoring device (dive computer, RDP/dive tables—which- ever you are trained to use) when scuba diving. Deny use of my equipment to uncertified divers.

4. Listen carefully to dive briefings and directions and respect the advice of those supervising my diving activities. Recog- nize that additional training is recommended for participation in specialty diving activities, in other geographic areas and after periods of inactivity that exceed six months.

5. Adhere to the buddy system throughout every dive. Plan dives – including communications, procedures for reuniting in case of separation and emergency procedures – with my buddy.

6. Be proficient in dive planning (dive computer or dive table use). Make all dives no decompression dives and allow a margin of safety. Have a means to monitor depth and time underwater. Limit maximum depth to my level of training and experience. Ascend at a rate of not more than 18 metres/60 feet per minute. Be a SAFE diver – Slowly Ascend From Every dive. Make a safety stop as an added precaution, usually at 5 metres/15 feet for three minutes or longer.

7. Maintain proper buoyancy. Adjust weighting at the surface for neutral buoyancy with no air in my buoyancy control device. Maintain neutral buoyancy while underwater. Be buoyant for surface swimming and resting. Have weights clear for easy removal, and establish buoyancy when in distress while diving. Carry at least one surface signaling device (such as signal tube, whistle, mirror).

8. Breathe properly for diving. Never breath-hold or skip-breathe when breathing compressed air, and avoid excessive hyperventilation when breath-hold diving. Avoid overexertion while in and underwater and dive within my limitations.

9. Use a boat, float or other surface support station, whenever feasible.

10. Know and obey local dive laws and regulations, including fish and game and dive flag laws.

I have read the above statements and have had any questions answered to my satisfaction. I understand the importance and pur- poses of these established practices. I recognize they are for my own safety and well-being, and that failure to adhere to them can place me in jeopardy when diving. 

MEDICAL STATEMENT
Participant Record (Confidential Information)

Please read carefully before signing.

This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered by All Staff & Instructors and Instructor Culebra Divers located in the Facility city of Culebra, state/province of Puerto Rico.

Read this statement prior to signing it. You must complete this Medical Statement, which includes the medical questionnaire section, to enroll in the scuba training program. If you are a minor, you must have this Statement signed by a parent or guardian.

Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When established safety procedures are not followed, however, there are increased risks.

To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely.

If you have any additional questions regarding this Medical Statement or the Medical Questionnaire section, review them with your instructor before signing.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
I wish to receive Culebra Divers quarterly email newsletter (I can opt out at any time).
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Date of Tour

Divers Medical Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes
Are you over 45 years of age AND can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*
No
Yes

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Heart attack?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.


Certification Level (Open Water, Advanced, etc.)

Date of Certification

Certification Number

Total Number of Dives to Date

Date of Last Dive
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
How did you hear about us?*

If Other:
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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